Continue CPR if there is an a-line pulse, but the pressure is low

Percussion Pacing

The Ethics of Different Capabilities at Geographically Close Hospitals

I want to hear what you folks think about this. Should all sick patients be taken to the closest hospital that has the most potential life-saving capabilities? Is there ny reason to bring really sick patients to tiny hospitals if the trip to a more advanced hospital only adds a few minutes? Let me know in the comments what you think.

The Mind of a Resuscitationist – A Resuscitationist Agonizes

This is why I really wanted to post this podcast. I run a series called the Mind of a Resuscitationist. For instance, the episode on

Today’s episode hits another key point to a resuscitationist’s mind: we agonize. We dissect every case that did not go perfectly to figure out if there was ANYTHING that could have gone better, been done smoother. This obsession leads to ulcers and interrupted sleep patterns AND better outcomes in the future.

Share this:

Related

Cite this post as:

Scott Weingart. Podcast 82 – Mind of the Resuscitationist with Cliff Reid. EMCrit Blog. Published on September 17, 2012. Accessed on December 10th 2016. Available at [http://emcrit.org/podcasts/mind-resuscitationist-reid/ ].

Discussion

thanks guys for an awesome podcast. v helpful. its not easy to share challenging cases in public so appreciate the effort!
Asystolic arrest with cardiac standstill on echo..tough case right off the bat!
Cliff, sounds like you gave excellent care from a clinical and human factors viewpoint. I understand your agonising. it means you care about what you do. You have passion and fire for clinical excellence. thats cool!
Scott, about your question regarding smaller hospitals and transferring to larger tertiary ones, the evidence suggests benefit in severe trauma and STEMI. For cardiac arrest of uncertain origin, zero evidence area for now. Work out of USA just published by your colleague Bellezzo suggests ED initiated ECMO is feasible with some good outcomes. This is the future happening right now and indeed in a few years time we may well see the techniques and devices and training more available in EDs . But in my view the most benefit to be gained right now in EMS and prehospital arrest care is in work done showing onscene ALS till ROSC or mechanical CPR devices intransport gives you an advantage. Victorian MICA paramedics work the code onscene and call it there if no response. This would have avoided the situation Cliff was faced with. Perth paramedic service are introducing the LUCAS mechanical CPR device to allow continuous quality Chest compressions to continue during transport and this allows more flexibility in travelling further to a higher centre hospital with things like ECMO, PCI etc. The rate limiting factor for now in EMS prehospital ALS care is the ability to continue Quality CPR during transport, which is why going to the nearest hospital makes tactical sense. The Japanese HEMS units are fielding the Autopulse device to allow continuous CPR during HEMS transports to a PCI hospital.
I commend everyone involved in the case and do not infer that the paramedic ALS cAre provided was nothing but excellent. I am always amazed by the ability of my paramedic colleagues who can provide CPR during road transport. I would much rather they be given the skills and credentialling to work the code onscene, call for backup as needed and finally to call the arrest if required.

Thanks for such a great podcast. Sorry I have nothing to add. As a young doctor all I can say is that I truly appreciate the work you guys do and the fact you guys share it with us to learn and improve the care we give our patients.

I would love to hear more on no external compressions in Traumatic arrest.
Minh……we participated in the “Aspire” trial and used the Autopulse years ago. Simply put it did great CPR……….however the trial was suspended early due to safety measures and some data that in the V-fib arrest it had worse out comes. We as field staff never understood that but alas the Autopulse machines disappeared from our rigs early in the trial.

Really enjoyed this Scott, engaging and thought provoking, with a few pearls as always. I think the “mind of the resuscitationist” reflects Cliff’s caring and striving for an optimal outcome, rather than just unthinkingly following an algorithm. That demonstration of “care factor” would have been a great learning point for his team, and now for us too.

Such a great discussion. Thanks Cliff and Scott for bring to light some great resuscitation pearls. I wanted to add a few comments.
1. As far as lines in cardiac arrest: I have completely gone to using IO lines. I place humoral IOs in all our cardiac arrests and have moved away from any central line use. It’s faster, cleaner and less likely to have a complication. We’ve been doing this for a while with enormous success as far as getting faster lines with fewer complications. The nurses are also more willing to hang pressors with the IO lines vs peripherals.

2. I’ve been very interested in the research on using vasopresin, epinephrine and solumedrol intra-arrest. It seems to have great success and I’m looking forward to further research on this. From what I’ve read on this cocktail so far it seems pretty impressive.
Arch Intern Med. 2009 Jan 12;169(1):15-24
Vasopressin, epinephrine, and corticosteroids for in-hospital cardiac arrest.

3. The final comment I’d like to add is the use of intra-arrest hypothermia. At our shop, once we have an IO placed we’ve been pressure infusing cold saline as part of our resuscitation efforts. We’ve found similar results as the research shows that intra-arrest vs post arrest hypothermia helps with post arrest ventricular function.
Crit Care Med. 2008 Nov;36(11 Suppl):S434-9.
Intra-arrest rapid head cooling improves postresuscitation myocardial function in comparison with delayed postresuscitation surface cooling.

Now I have a question?
What do you think about using the CPAP vent setting with a low setting for passive oxygenation and moving away from active ventilations during witness cardiac arrest? We know it has been very successful for paramedics in Arizona with using a NRB vs bagging during the arrest.

Scott,
My understanding of the work that led to the impedence threshold device is that applying a CPAP or PEEP to a pt in cardiac arrest is exactly what you should NOT be doing. The ITD creates a larger negative intrathoracic pressure with chest recoil by limiting airflow into the lungs, thus improving venous return to the heart. PEEP will apply a positive pressure to the lungs and thus impair venous return.

In cases where I leave a pt on the vent in a cardiac arrest, I turn the PEEP to 0.

Sean Agree that is why the ITD must be there. But now I am thinking the ITD would not impede the CPAP in its current form. So I’d actually want the ITD to block the CPAP except for 10 episodes/per minute. My whole thinking is to eliminate the need to time breaths.

Haha, I think you just spun full circle… An intermittently delivered CPAP is exactly the same thing as a pressure control breath with 0 peep.

The design of the ITD is such that you give a positive pressure breath with O2 delivered during that breath and in between breaths you give no gas flow at all. If you buy into the ITD concept, you have to abandon the passive oxygenation idea, the jury may be out but my reading of the literature suggests that’s the smart bet.

In response to “The Ethics of Different Capabilities at Geographically Close Hospitals.” I think it is tough to bypass any ED with an asystolic patient in the back of the ambulance even if the trip to a quaternary medical center is 15 minutes further.

I am in a metro area where there are several community hospitals < 30 minutes from the university hospital.

For trauma, STEMI and stroke certainly bypass the community hospital.
I would suggest bypassing for the cardiac arrest patient with prehospital ROSC who remains unconscious. This patient would benefit from hypothermia and PCI not readily available at the community hospital.

I would take the arresting trauma patient to a community hospital because they need immediate treatment (chest tubes, thoracotomy). This treatment can't be provided in the field but can (hopefully) be provided at any ED. Once the patient is alive again they can go to the trauma center.

The difficult decision about where to transport a questionable patient should involve a discussion between medics and command docs.

not sure what these small hospitals have to offer that the medics are not already providing. If these pts are going to make it, they need a center that can provide perfect hypothermia, meticulous post-arrest care, cath, and in a few years ED ECMO.

I agree that in a medical arrest small hospitals don’t have much more to offer.

However in the case of traumatic arrest U.S. medics can perform needle thoracostomy but are unable to perform chest tube or prehospital thoracotomy. A smaller hospital with an ED should be able to provide these procedures. We know CPR and ACLS drugs don’t help the traumatic arrest patient and that is what EMS is offering on the way to the trauma center.

It all depends on the capabilities of the hospital you are considering bypassing and the capibilities of the hospital you would be diverting to. I would argue that small hospitals (really anything under a Level II trauma center) offer little-to-no benefit to trauma/trauatic arrest patients and in most cases actually harm them by increasing the time to definitive care. In fact, every traumatic arrest that I have ever seem brought into any non-trauma center by (ALS) EMS has been called at the door.

In most areas of the US, EMS protocols have been updated to reflect these realities, and they MANDATE transport to a trauma center if one can be reached in under 90 minutes.

Many of these small hospitals are not set up to handle major trauma patients with any sort of rapidity, so getting blood might take 30 minutes, etc. Also, while technically the ED physician should be able to preform the lifesaving procedures mentioned above, many have not attempted these since their residencies (or in the case of EDs staffed by family practice physicians, have never attempted these procedures.)

Mate, agree with you on penetrating trauma and witnessed arrest = prehospital thoracotomy.
blunt traumatic arrest = evidence base the same as CPR and epinephrine = not much evidence for traumatic arrest benefit.
clinical equipoise = CPR as good as thoracotomy in blunt traumatic arrest
I challenge you to the case of Princess Diana. When she arrested on extrication from her car, they gave her CPR which achieved ROSC. Would a prehospital thoracotomy have been a superior technique for her arrest?
the full Scotland Yard report into her accident and prehospital care is herehttp://downloads.bbc.co.uk/news/nol/shared/bsp/hi/pdfs/14_12_06_diana_report.pdf

Another interesting issue is the use of atropine. The 2010 guidelines took atropine out of the asystolic and PEA guideline with a IIb recommendation, however most of the medications in ACLS have a IIb recommendation. If you look at the references they used to make the decision to remove atropine from the guideline they were published before hypothermia was routinely utilized. In a number of the studies they say there was greater success of ROSC using epi/atropine than with epi alone but they had a worse neurologic outcome. I wonder if this would still exist in the hypothermia age?

I’m a believer that atropine may be effective for selective cases of asystole in which you are right there and the arrest is the likely result of a surge in parasympathetic tone (https://www.kg-ekgpress.com/acls_comments-_issue_07/#Survival%20Differences%20IN-%20vs%20OUT-%20Hospital ). While not harmful – it sounds like the arrest in this case is not related to enhanced parasympathetic tone – but rather PEA from likely large acute STEMI – in which case atropine is unlikely to have any effect … (Like Cliff said for the question about trying Bicarb – “sure” if you want – though wouldn’t expect atropine to work in this case).

Great discussion – although I almost crashed my car at 6am driving to work because I was so caught up in listening to the podcast!

In my corner of the UK, where we have a Physician/Paramedic HEMS team, our policy is to carry out resuscitation at scene until we either get a ROSC or we call it. We don’t transport patients in arrest unless there are exceptional circumstances (e.g. paediatric, severe hypothermia).

As Minh points out, human provided CPR in the back of a moving vehicle (land ambulance or worse, helicopter) is really ineffective. Once we’ve achieved a ROSC we’ll then go to the most appropriate hospital – usually the one with a cath lab available and lots of experience in managing post arrest patients.

I think we need more focus on providing excellent quality resuscitation at scene followed by transfer to the most appropriate, not closest, hospital if a ROSC is achieved. Obviously, this is more practicable in some areas than others and is dependent on the skill set of the pre-hospital providers.

(Oh, and I entirely agree with Scott and Cliff about chest compressions in traumatic arrest – fairly pointless most of the time and probably leads to more harm than benefit. It’s a nightmare trying to stop people doing them though)!

It really brought back memories and feelings a case I had a couple months ago which in my mind mind really pointed out the inequalities in health care distribution between hospitals in close (or not so close) proximity. I work in a metropolitan area that has 2 main tertiary centers and multiple surrounding community EDs. I work at one of the tertiary centers and two of the community EDs. Most higher levels of care (PCI, trauma, stroke…even OB) have been relegated to the larger hospitals leaving the other community EDs with nice shiny EMERGENCY signs in front but not that much to back it up at times.

THE CASE:
Got to work at 7am at one of the community EDs, first patient at 7:10. 62 year old female with history of only HTN comes in with CP. Since the ED was empty I met her in the room and was interviewing her as the nurses and techs were getting her onto the monitor. Prior to her being hooked-up she arrested in front of me. One minute talking and next… CPR within 30 seconds. PEA on the monitor with large anterior STEMI. No cardiac motion on bedside US. Long story short we worked on her for >60 minutes with no response. She got quality compressions right awayand throughout, EPI, Calcium, TPA at the 10-15 minute mark, cold fluid, and Cliff I even gave Bicarb…what the hell. I never got back any really good cardiac function on bedside US. Cardiologist came down from upstaris, stood next to me and said, “That’s all you can do.” Her husband was in the room the entire time and was grateful for all we did.

The rub of the case for me was this: the hospital I was at is 4 miles from the large tertiary care center I work at as well. If she had presented there instead I would have had 24 hour PCI, and maybe would have been able to talk someone into ECMO. I don’t know if any of these would have benefited the patient but I would have felt like I offered her everything.

When it’s someone’s time, it’s someone’s time. But the feeling of thinking I could have done more sucks.

Coming from an RN, great show, I love listening to and picking Intensivist minds about cases, it allows me to see your thinking in cases and allows me to broaden my education and thinking to allow better patient care as well. I know in this situation Dr. Reid did not have access to, but if you did what about an implant of bilateral Ventricular Assist Device?? I understand this would be much more work and time consuming and Ecmo would be preferred for oxygenation and decrease workload, but if one was able to sustain this patient to the operating room place them on bypass. Would you consider this therapy?

What a great podcast from a great bloke. Cliff I shared a few chest thud eye wipes during that one…..
With the provision of prehospital care being ever more advanced in most developed countries I can’t see the that the argument of going to the nearest holding any water. As Scott said there is nothing worse than dead, and CPR is merely a bridge to definitive care. The caveat is that there is plenty of evidence showing that CPR in a moving vehicle is ineffective and hazardous to the user. I think IPPV with an impedance threshold device, some form of automated external compression decompression, intra-arrest cooling, epinephrine administration to maintain a diastolic over 40 with CaCl as an early adjunct with direct transfer to a centre that offers front door ECMO and PCI is the only logical solution to offer these potentially salvageable young people. Asystole has poor prognostic likelihood with our current treatment paradigms; what is the prognostic value of asystole in the hypothetical system I described above.
You not dead until you are cold, bypassed, PCI’d and dead!
I agonise over many cases. I am glad (for once) to hear I am normal!
Respect.
JF

I had intended to bring up automated CPR in the conversation. We used the LUCAS device routinely in my UK ED for years and it felt really barbaric coming to Australia and watching everyone do it the caveman way. I was used to patients coming into ED having been intubated in the field and the nurses would apply the LUCAS immediately and we’d put the patient on a ventilator. No-one had to think about BLS – it was delivered far more effectively by machines and that way all action and thinking could be directed toward diagnosis and targeted therapy (with scornful disregard of the Hs and Ts system – but that’s for another podcast!).

The LUCAS was a game changer because we had to discard the use of ETCO2 as a prognostication tool – everyone got an effective circulation regardless of down time; I reckon the LUCAS would give Tutankhamun a decent ETCO2. It also helped us get some arrest patients to the cath lab. James French and Ed Valentine may remember some of those cases, since I was lucky enough to work with both those guys!

Cliff, I would encourage you to please consider recording a podcast on the automatedCPR and your current opinion, either on resusme, here or on my show.
I do not normally support the notion that technology should replace basic skills and tactics, for example, I do not believe now that video laryngoscopy should ever replace direct laryngoscopy. However in chest compressions and BLS, I do wonder what benefit we are doing by training people via costly courses and trying to get them to provide excellent BLS in oft difficult conditions. ?…when we have devices that can do it better and longer and allow us human providers to focus on other critical reeuscitative measures. When I teach ALS I always see everyone focus on drugs, airway…why because its easier to do that and think we make a difference than the physical stress of good CPR..yet we know drugs and airway make very little difference to OHCA outcomes.
I started to form my world view on this when I had to actually give CPR inflight during an aeromedical retrieval and then interviewed colleagues who had to do the same. Try doing excellent solo CPR at 29000ft in a moving metal coffin…then you realise we are kidding ourselves with our current teaching and strategy.
Like VL the challenge now is the cost of these devices and making them widely available. I am not lacking hope here as we saw portable AEDs become affordable and widely distributed. Same with VLs, which are now hitting the personal price range. I predict that the automated CPR devices will reduce in price and become like the AEDS, widely available. In fact that is the ideal device a combined AED and CPR automatic pack.

But Cliff, I would love to hear your thoughts on all that so please consider!

Haha, I think you just spun full circle… An intermittently delivered CPAP is exactly the same thing as a pressure control breath with 0 peep.

The design of the ITD is such that you give a positive pressure breath with O2 delivered during that breath and in between breaths you give no gas flow at all. If you buy into the ITD concept, you have to abandon the passive oxygenation idea, the jury may be out but my reading of the literature suggests that’s the smart bet.

Not spun around, it just sounds that way b/c I am explaining myself poorly. I want negative pressure between breaths, but I want the breaths to be limited to very low pressure and rate.

I could easily achieve this with my vent on pressure control and an ITD just as you say, but the idea would be something you could do in the field with no machines. My modified conception of the ITD along with any high-flow CPAP set-up would work v. well without a machine to get you this. But as I think the ITD is built currently, the CPAP would still be delivered between breaths.

As to passive ox, we only need O2 to fill the oropharynx, we don’t need any actual pressure. Now would an ITD destroy apneic ox, that is an interesting question. I guess it might by pure pressure differential. Question is would the mixing from the compressions still exchange pharynx O2 with lower alveolar gas?

I’m still confused about what you are trying to accomplish, my friend. Re-reading your posts I gather the following: a BLS paramedic crew without training in intubation or supra glottic airways, taking care of a pt in cardiac arrest in the amb en route to your ER. It seems you are suggesting this pt gets15 LPM NP, a tight sealing facemask on top hooked up to the ITD and then a portable CPAP machine, not a BVM.

I don’t have first hand experience with the ITD but think I understand the mechanics involved. Depending on whether you set the CPAP above the ITD spring’s threshold or not (10cmH20), you would get either continuous CPAP applied and impair venous return or you would get no CPAP and the ITD would remain closed in this apneic pt who would receive Np O2 but no breaths. The CPAP machine in my estimation adds nothing here, if you are happy with 15lpm np for apneic oxygenation, you could leave the ITD connected to nothing.

Theoretically, if you aren’t concerned about the pt waking up and starting to breathe spontaneously in this scenario, you could use a cheap one way valve on top of the mask to allow exhalation rather than a pricy ITD

Nope, in its current form, ITD allows all ventilations in from above. It doesn’t allow ventilations in from below until you overcome the spring valve. Not talking a CPAP machine, CPAP set-up like the Boussignac or Flowsafe. Cost of the ITD is not to allow for this set-up, it is b/c I believe in the concept of the ITD. Would need only the alteration of only allowing breaths in during the time for breaths, i.e. 1 every 6 seconds for a period of 1 second. Given the ITD already has a timer built in and the valve structure, shouldn’t be a hard alteration. If you had that, you would have guaranteed rate, volume, low pressure, still get the negative IT pressure between breaths. Nobody needs to bag. Just hold on to the mask, LMA, or ET tube.

Ok, finally with you. The ITD would have to be modified as you mentioned, almost becoming an oxylator in addition to an ITD. But the concept is a good one to me. Would allow for set it and forget it ideal ventilation during a code, allowing personnel to focus attention elsewhere… Now you just need to invent it.

yes I was thinking about the oxylator whilst reading the two of you debate the setup! But currently as Sean says the oxylator would need a modification to avoid delivering positive pressure all the time.
To be honest that whole setup you two describe sounds freakin complicated.
What Cliff described of using the LUCAS and then a standard ventilator in ED resus sounds much simpler and feasible.
Prehospital resus you could still do that if you got a ventilator
If not then something like this might be even simpler and doablehttp://www.harvardapparatus.com/hapdfs/HAI_DOCCAT_1_2/VT46.pdf
Note how they used a mechanical chest compression device and ventilator as well in the study method.

Vent is easy to say and hard to use (though it is what I use during arrest). What Sean and I have been going back and forth about is extremely difficult to say and idiot-proof to use. If you think trans-trach is easier still then you are a better man than I.

Since we are into the increasingly theoretical realm of reimagined equipment already, perhaps we could imagine a “cardiac arrest hotkey” on a ventilator… To instantly change your settings to those appropriate for an arresting pt. This might pass your simplicity test as nicely as your alternative, Scott.

Thanks for the podcast as always, but I’d like to chime in on your question on the thought of regionalized care for patients post-cardiac arrest. Minh pointed out above that regionalization of care has resulted in improved mortality for trauma and it is believed to improve mortality in patients with STEMI. However, the RACE project and data published in Annals of this year suggests that the overall reduction in mortality in pre-hospital transferred patients with STEMI was similar amongst hospitals not involved in the program. Additionally the overall reduction in mortality seen nationwide based on medicare/medicaid data also saw about a 1% reduction in mortality (which is the amount seen in the patients who were transferred as part of the RACE program).

I’m not saying this data is definitive, but let’s be cautious about programs that move patients out of the nearest hospitals for more specialized-quaternary care hospitals until we have further data to suggest that their are improved patient-orientated outcomes.

As for the transfer of all cardiac arrest patients, although ECMO is an intriguing option, I’m not sure what most “specialized centers” have to offer to a patient in asystolic arrest. I agree PCI and cooling are crucial, but even so in the United States Cardiologists are weary of taking patients to the Cath lab post-arrest unless there is a STEMI. As I am sure you know (and has been my experience) cardiologists get dinged for every patient who goes to the cath lab and dies, which is the unfortunate fate of many of our post-arrest patients, despite aggressive therapy. I find cardiologists are more inclined to take patients with VFIB/VTACH arrest, short downtimes, in previously healthy individuals, or patients who had an intra-inter departmental arrest.

As for ECMO which sounds promising, I know the battle I have fought for MICU patients to go on ECMO with severe IPF or ARDS (and there are RCT to support its use) and as an already busy LVAD and heart transplant center I wonder how using it in a subset of patients with arbitrary inclusion criteria without any real RCT supporting it would play out? I’m just speaking logistics here not idealistically.

I digress to say that regionalization of care for STEMI/arrest/CC/Stroke and the list goes on needs to demonstrate to me improved patient-orientated outcomes not “door to balloon time” before I can jump on the bandwagon. Maybe the answer is better education for physicians, nursing, and staff on the non-sexy “style” points of care at all hospitals; stroke care for example is likely improved at regionalized centers because nursing, physical therapy and speech therapy are more adept at caring for these patients, rather than regionalized care.

Regardless of ECMO and PCI, the reason patients do better at cardiac arrest centers is familiarity with the post-arrest syndrome and the ability to respond to it aggressively. While the data are not clear, studies are bearing this out, for instance Carr’s work.

Most small hospitals can’t pass muster for full-bore critical care. There are some that can and these centers should definitely be able to become arrest centers.

Forgive me b/c of my youth (as I’m only a couple years into EM training), but to me resuscitation centers make sense. Why send a patient that needs specialized care to a place that only performs that care a few times a year? My point is that the patients I remember the most are the one’s that I have made mistakes and learned from. Places that only see a “few” cases really can’t get this same experience. I’m not just talking about physicians either. I’m talking nursing, RT, protocols that have been attempted and revised, specialist referrals and expertise that a require bedside care. Maybe it’s just my youth, but this just makes sense. If I were to have a cardiac arrest, I want to be where Dr Abella is at that evening (ie no offense Dr Weingart). If I develop septicemia, I want to be at a place that sees 1000 patients a year with this, not the place that takes care of a handful. Experience for all staff involved is priceless. Maybe there’s not a ton of data to support this but sometimes we get so caught up about data that we miss the simple points that the data does not represent what might be the best for our patients. Great post!!!

Joe Wrote: “I think it is tough to bypass any ED with an asystolic patient in the back of the ambulance”

I think it is tough to justify starting to the ED with an asystolic patient in the back of the ambulance. In an extraordinary case, like the one described by Cliff Reid, yes. But there should be a very good reason.

Sure it sucks to pronounce someone dead while you’re looking at their kids’ artwork on the fridge or family pictures on the mantle, but that is part of prehospital medicine. In most cases, field pronouncement is the responsible and reasonable choice after an unsuccessful resuscitation.

I enjoyed podcast and found interesting from academic standpoint. I work in small community hospital, single MD coverage. I would have called code with asystole and cardiac standstill on US regardless of age . Let’s say on case discussed in podcast that ROSC was achieved, in reality is there any chance pt would have left neurologically intact? If not then doing exercise of prolonged ACLS/resusitation, especially in single coverage ER, prevents all other ER pts from receiving care and adds extreme cost to case study pt (say if you got him to ICU for day or two) without return to quality of life.
I hope I do not appear too cynical, just trying to be practical.

Sorry I’m a bit late in the discussion, just listened to this podcast. Love the show Scott – makes me think every time. I want to comment on the “travel to nearest hospital” issue. All of the above commentary has focused on possible improved outcomes for the occasional patient. I am an advocate for the nearest hospital because I work in a community hospital and see the problems of ambulances bypassing me with trauma, STEMI, stroke, anyone who might potentially need tertiary care. The big hospital is 45 min away. The issues are:
1. I have 10 consultants (attendings) and all the nurses who are steadily de-skilling, making retention of these people difficult
2. The bypass system is only about 90% so we still get these cases, but we are no longer slick at them
3. I employ a large number of trainees who are not exposed to certain cases, making recruitment difficult
4. The local community expects a high quality ED, which is harder to maintain given the above issues.
5. We can’t send everyone to the big hospital. They get overloaded with “potential”serious cases that could have been managed in my shop
6. All the bypassed patients are stuck in a distant hospital isolated from family
7. This system is very expensive
8. All this for probably a very small number of better outcomes.

I would prefer to see the community hospitals have better resources and training.

Wow Chris – You open a whole “can of worms” in terms of whether to “bypass” the “nearest hospital” or not. In primary care (where I taught and worked for 30 years until recently retiring from practice) – there were similar issues of this “Catch-22” where one becomes very good at what one does – but then gets caught into a vicious cycle being less good when not regularly “doing” a procedure – leading to doing even less and less. As you state – BEST to find that “happy medium” between when to go to the “Big House” vs the “nearest facility” leading to optimal patient flow and optimal patient outcomes. GREAT POINT you make!

There are 2 ways to run a small shop. You can have the classic community hospital: the ED doc is the only actual doc in the house at night, no tertiary services, ICU is actually seeing what would predominantly be step-down pts in other hospitals, etc. In these places, the ED can be top-notch, but the pt will not do well. We in the ED only provide a small portion of a sick patient’s care.

or

You can run a small shop with all of the services, but just less of each doc in each dept. For instance you can have a PCI program with only two interventionalists. As a patient you actually would do better in this situation. WIth only two docs, they get a ton of experience and there is no variance from each of 10 docs doing things differently.

You get 4 great intensivists in a multi-disciplinary ICU. Recruit 6 general surgeons who can do trauma, a couple of neurosurgeons, and a in-house hospitalist who can do procedures and run codes. All of a sudden you have a small community place that is offering everything, doesn’t have residents killing pts every July, and is tight-knit family that can actually communicate instead of throwing messages over the wall of academic dept fiefdoms.

? is which kind of community hospital do you work at? ED folks getting experience is not worth it if the patient will wind up at the 1st type of community hospital and then need transfer.

STUDY OBJECTIVES:
The aim of this study was to evaluate the risk of prolonged transportation against the benefit of treatment in high-volume centres for out-of-hospital cardiac arrest (OHCA) patients without prehospital return of spontaneous circulation (ROSC).
METHODS:
This study used a nationwide EMS-assessed OHCA database (2006-2008). Patients with cardiac aetiology were selected from the registry. A high-volume centre was defined as a hospital that received an average of more than 33 cases per year. OHCA patients without prehospital ROSC were divided into subgroups according to their destination (high-volume centre vs. low-volume centre) and transport interval. The rates of survival to discharge were compared among these groups using multivariate logistic regression analysis.
RESULTS:
During the study period, 54,499 OHCA patients were assessed by EMS in Korea. Of these patients, prehospital resuscitation was attempted for 29,345 patients with presumed cardiac origin. After excluding cases with inappropriate time data, 27,662 cases were selected for further analysis. 15,885 (57.4%) patients were transported to low-volume centres while the rest were transported to high-volume centres. The rate of survival to discharge was 1.43% and 4.78%, respectively. A multivariate analysis indicated that even with a longer transport interval (TI)(TI 5-9min vs. TI 0-4min), the high-volume centres presented a better overall outcome.
CONCLUSION:
A higher rate of survival to discharge was demonstrated when OHCA patients without prehospital ROSC were transported to high-volume rather than low-volume centres. The rate was still significantly higher when the transportation time was longer compared with that of low-volume centres.

Interesting comment Cliff (!) – and without access to PubMed I don’t have the original article. Clearly the large numbers of patients studied is impressive – but looks like it is a data registry (ie, retrospective) – and lots has changed in just the past couple of years in this country – so unknown how the 2006-08 experience in Korea compares to what is currently being done. Potentially problematic with this study is the “unknown” of why patients went to a “high-volume” vs “low-volume” center (some self-selection?) – and I’m curious as to why an average of “33” (rather than 32 or 34) cases per year was defined as “high-volume” (usually suggests some retrospective data-snooping … ) – so all in all, I’m not sure how much in terms of “firm conclusions” can be drawn from this.

That said – what seems to be apparent at the current time is that care at “experienced centers” with focus on optimizing resuscitation (be this with increased emphasis on high-quality CPR with minimal interruption, cooling, quality post-resuscitation care [including prompt cath when appropriate]) all seem to be making a decided difference toward improving survival rates compared to “low-volume” centers that have not evolved with recent advances.

not really much of a difference in transport times. previous studies agree with this, post-arrest patients do better at centers that are experienced with post-arrest care. another one to add to the database.

Comment Policy:Your words are your own, so be nice and helpful if you can. Please, only use your real name and limit the amount of links submitted in your comment. We accept clean XHTML in comments, but don't overdo it please.

[…] makes a good Resuscitationist, as wisely pointed out by Scott Weingart and Cliff Reid in a recent podcast. And there would quite clearly be learning points to take away from a case like this. However, […]

Other Stuff

When you're done listening to the podcast, check out these great sites.

Who are We?

Hi, my name is Scott Weingart. I am an ED
Intensivist from New York. Along with my friends, we are attempting to provide and teach Maximally Aggressive Care, Everywhere! From the field to the ICU, EMCrit is about optimal critical care and resuscitation.